Much to their surprise, the woman opened up her eyes, proving that the rumors of her death had been greatly exaggerated.
The patient was Colleen S. Burns and the state Health Department found St. Joe’s care of her in 2009 “unacceptable” and the hospital was criticized by a federal agency for not properly investigating the cause.
St. Joe’s mishandling of the case resulted in their being fined $22,000 last September, which was the largest fine levied against a Central New York hospital since 2002.
The hospital was fined $6,000 over the Burns case and $16,000 for leaving a patient unattended before she fell and injured her head in 2011.
Even after reviewing 10 years of inspection records, the state could not find a case similar to the Burns case.
What was the “perfect storm” of mistakes that led up to a living patient being pronounce dead?
There were a flurry of mistakes that led up to Colleen Burns being pronounced dead when she was very much alive.
Burns arrived at St. Joe’s suffering from a drug overdose, according to the investigations that took place.
A review by the state Health Department found, among other mistakes, that:
Staff skipped a recommended treatment to prevent the drugs the patient took from being absorbed by her stomach and intestines.
*Not enough testing was done to see if she was free of all drugs.
*Not enough brain scans were performed.
*Doctors ignored a nurse’s observations indicating Burns was not dead and her condition was improving.”
Until it was prodded by the state, the hospital made no effort to thoroughly investigate what went wrong. According to the investigation, St. Joe’s had acceptable organ procurement policies and procedures, though they apparently weren’t sure what the exact demarcation points were between the living and the dead.
Recovered from her overdose of Xanax, Benadryl and a muscle relaxant, Burns, 41, of North Syracuse, was discharged from the hospital two weeks after the near-miss in the operating room.
Sadly, 16 months later, in January 2011, she committed suicide, said her mother, Lucille Kuss.
According to Kuss, having her daughter mistaken as dead and nearly cut open at the hospital was a horrible experience for the family. She said the doctors never explained what went wrong.
They were just kind of shocked themselves. It came as a surprise to them as well.”
Burns, the mother of three daughters, was never upset about the incident, her mother said.
Kuss said, “She was so depressed that it really didn’t make any difference to her.”
Despite their obvious misdiagnosis, St. Joe’s was not sued by Burns or any of her relatives.
Burns’ family asked St. Joe’s officials not to discuss the specifics of the case, hospital spokeswoman Kerri Howell said.
Howell said in an email to The Post-Standard: “St. Joseph’s goal is to provide the highest quality of care to every patient, every time.” She said the hospital works with Finger Lakes Donor Recovery Network to follow strict policies and procedures for organ donation.
These policies were followed in this case, which was complicated in terms of care and diagnosis. We’ve learned from this experience and have modified our policies to include the type of unusual circumstance presented in this case.”
According to documents obtained by The Post-Standard under the state Freedom of Information Law, St. Joe’s officials thought Burns suffered “cardiac death” in October 2009.
After they were told she was dead, her family had agreed to allow doctors to withdraw life support and remove her organs.
A nurse had performed a reflex test on Burns the day before her organs were to be removed, scraping a finger on the bottom of her foot. The nurse did not get the expected reaction of someone who’s supposed to be dead. The toes curled downward.
Other indications that Burns had not suffered irreversible brain damage, as doctors had determined, were that her nostrils flared in the prep area outside the OR. Also, she seemed to be breathing independently from the respirator she was attached to, and her lips and tongue moved.
According to records, a nurse gave Burns an injection of the sedative Ativan twenty minutes after those observations were made.
There’s no mention of the sedative or any indication they were aware of her improving condition in the doctors’ notes.
Still, even with all of these signs that Colleen was, in fact, alive, none of them were enough to stop the organ-harvesting process. It wasn’t until Burns was wheeled into the OR on Oct. 20, 2009, opened her eyes and looked at the lights above her that doctors called it off.
Burns had been in a deep coma from taking an overdose of drugs. Hospital personnel misread that as irreversible brain damage without doing enough to evaluate her condition, the state Health Department found.
According to Lisa McGiffert, director of Consumers Union Safe Patient Project, there is no way of knowing how often near-catastrophes like the Burns case happen because there is no system in place to collect information from hospitals about medical errors.
These sorts of things do happen. It’s pretty disturbing.”
Her organization believes states should require hospitals to report all such incidents soon after they happen.
That would require people to think about how to prevent it in the future,” she said. “If you don’t have to account for it, that doesn’t always happen.”
A nationally known forensic pathologist out of New Jersey, Dr. Charles Wetli, said:
Dead people don’t curl their toes. And they don’t fight against the respirator and want to breathe on their own.”
According to Wetli, once those signs of life appeared, the organ-harvesting process should’ve stopped.
Wetli wondered why a nurse would give Burns a sedative after seeing signs that she was alive.
Dr. David Mayer, general and vascular surgeon and an associate professor of clinical surgery at New York Medical College, also reviewed the records and found the use of a sedative perplexing.
It would sedate her to the point that she would be non-reactive. If you have to sedate them or give them pain medication, they’re not brain dead and you shouldn’t be harvesting their organs.”
According to Mayer, the hospital erred four or five times. He called the case a gross deviation from all prevailing and accepted standards of care.
It’s a good humanitarian service to fill out an organ donor card, but cases like this one where doctors at St. Joe Hospital tried to remove the organs of a living woman might make some people pause before they sign on the dotted line.
Written by: Douglas Cobb